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Case Report

Manic episode after Amisulpride monotherapy : an unexpected presentation.

Priyanka Jog1 Devavrat Harshe2 Deoraj Sinha3 Ravindra Kamath4

1Resident Doctor 2Senior Resident Doctor 3Assistant Professor 4Professor and Head Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai. E-mail –[email protected]

ABSTRACT

Amisulpride is anunique atypical antipsychotic with a mechanism of action on dopamine receptors that is effective in positive as well as negative symptoms. There are some reports of Amisulpride being useful in treatment resistant depression as well. Mania has been reported as a result of Amisulpride so far in only two cases. We present here as case with psychotic features that developed mania induced by Amisulpride at a dose of 150mg.

Key words:Amisulpride, mania, drug induced mania.

INTRODUCTION

Among all atypical antipsychotics, Amisulpride has few unique properties. It has minimal affinity for 5-HT2 receptors. It also has affinity for D2and D3receptors. Perhaps these properties of Amisulpride have resulted in it being described as an unusual atypical antipsychotic [1]. Like all psychopharmacological agents, Amisulpride is associated with certain adverse effects. Common adverse effects reported with Amisulpride are extrapyramidal side effects (dystonia, tardive dyskinesia), drowsiness, agitation, anxiety, hyperprolactinemia, galactorrhoea, gynaecomastia, and amenorrhoea. Rare effects include NMS, reduction in seizure threshold, hypotension and QT prolongation [2-3].

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Apart from all these, manic episodes after initiation of amisulpride in management of schizophrenia have been reported. We could find only 2 reports [4-5] in the literature and hence, decided to present this case.

CASE REPORT

An18yearoldmale presented with aggressive abusive behavior,social withdrawal, disturbed sleep and preoccupation with thoughts about his appearance since 2 years prior to presentation.The patient was admitted in the ward and was investigated with routine investigations (complete blood counts, liver and renal function tests).It was reported by the caregivers that a year prior, the patient had a similar episode and was treatedwith Amisulpride (dose unavailable) on which the patient and relatives reported approximately 75% improvement. Considering this history, Amisulpride was restarted at a dose of 50 mg.The dose of Amisulpride was titrated upto 150 mg over next 7 days by 50mg increments every 3 days. Within 48 hours after the dose titration to 150 mg, the patientdeveloped a decreased need for sleep, increased psychomotor activity, distractibility, disinhibition,inappropriate laughter,overfamiliarity,jocularity,sudden anger outbursts and irritability. Mental status examination showed ill sustained attention, rapidly established rapport, elated mood, flight of ideas, clang association, pseudo- philosophical ideas. Severity of symptoms on Young Mania Rating Scale (YMRS) [6] was 22.Amisulpride was stopped and the patient was started on Haloperidol 5mg and Trihexyphenydyl2 mgorally per day. The dose of Haloperidol as titrated to 10 mg respectively over next 4 days.YMRS score dropped to 17 after day 4, 10 after 7 days and 0 after 2 weeks of treatment.The patient showed full symptomatic recovery for all manic symptoms over the next 7 days with a rapid improvement in all psychotic symptoms as well.

DISCUSSION

Drug induced mania or “poop out” phenomenon is a big concern in clinical practice. Sudden change in patient’s mood and behavior ranging from hyperthymia to hypomania to a full blown manic episode, especially after the treatment can cause anxiety, apprehension, fear and distrust towards the treatment in the mind of caregivers. It also leads to an increase in caregiver burden due to increase in inpatient stay and an increase in treatment cost incurred due to switching the culprit drug with another.Common drugs implicated in drug-induced mania or switch, are usually antidepressants in all groups with a higher risk in tricyclic antidepressants and selective serotonin reuptake inhibitors with the least risk being with Bupropion. It is ironic that although atypical antipsychotics are often used for the treatment of manic episodes, literature exists to show a manic switch with Olanzapine, Risperidone, Clozapine, Quetiapine, Ziprasidone, Aripiprazole, Amisulpride, Zotepine and Paliperidone [3] totaling to 28 cases being reported. It is worth mentioning that we were unable to find case reports mentioning a manic switch/episode after first generation antipsychotics.

To the best of our knowledge, only 2 case reports of Amisulprideinduced mania exist in the literature. The first case report [4] described a manic episode in a patient diagnosed as schizophrenia with 400 mg Amisulpride and 20 mg Citalopram who developed mania after 90 days of Amisulpride treatment. However, the second case report [5] presents the case of a patient diagnosed with schizophrenia, treated with 4 mg Risperidone for 1 and a half-year, augmented with Amisulpride 100mg and the patient presented with a manic episode after 10 days of treatment.

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It has been demonstrated that, the risk of antidepressant induced switch is more in patients with bipolar I disorder, lower age at onset, hyperthymic temperament and those on lithium [7]. However, no such risk factors have been identified for antipsychotic induced switch. Since almost all the cases of antipsychotic induced switch (AIS) are after atypical antipsychotic regimen, the cause can be hypothesized to be the action on serotonergic receptors.Further research is vital in this domain, to evaluate the incidence of AIS, as well as the risk factors associated with it. This is particularly important for Amisulpride, Quetiapine and Aripiprazole, which are used in treatment of depressive disorders and a switch after using them cause considerable distress and burden to the patient, the caregiver and the treating doctor as well.

REFERENCES

1. Leucht S, Pitschel-Walz G, Engel RR, Kissling W. Amisulpride, an unusal “Atypical” antipsychotic: A Meta-Analysis of randomized controlled trials. Am J Psychiatry 2002;159:180-90. 2. Chhabra V, Bhatia MS. Amisulpride: a Brief Review. Delhi Psychiatry Journal 2007;10(2):140-3. 3. Benyamina A, Samalin L. Atypical antipsychotic-induced mania/hypomaia: a review of recent case reports and clinical studies. Int J Psychiatry Clin Pract.2012; Mar 16(1): 2-7. 4. Murphy BP. Amisulpride-induced mania in a patient with schizophrenia. Br J Psychiatry 2003;183:172. 5. Agarwal A, Jain M, Khandelwal A, Jiloha RC. Amisulpride induced mania. Indian J Pharmacol. 2010;42(2):112-13. 6. Young RC, Biggs JT, Ziegler VE, Meyer DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133(5):429-35. 7. Henry C, Sorbara F, Lacoste J, Gindre C, Leboyer M. Antidepressant-induced mania in bipolar patients: identification of risk factors. J Clin Psychiatry 2001;62:249-55.

Acknowledgements – Nil Conflict of Interest – Nil Funding - Nil

Indian Journal of Mental Health 2015; 2(2)